Effects of trauma quality improvement program implementation on mortality: A multicenter controlled interrupted time-series study

Abstract

AbstractImportanceTrauma causes over four million deaths annually, predominantly in low- and middle-income countries. Implementing trauma quality improvement programs may improve outcomes, and though extensively used, high-quality evidence of their effectiveness is scarce.ObjectiveTo assess if implementing a trauma quality improvement program using on audit filters improves trauma patients’ outcomes.DesignA controlled interrupted time-series study.SettingProspective, multicenter study across four tertiary care hospitals in urban India between 2017-2022.ParticipantsAdult patients admitted to participating hospitals with history a of trauma, defined as having any of the external causes listed in block V01-Y36, chapter XX of the ICD-10 as reason for admission.InterventionIn the intervention arm (two hospitals), a trauma quality improvement program using audit filters was implemented after a one-year observation period. The control arm (two hospitals) continued baseline data collection without intervention throughout the study period.Main OutcomesAll-cause mortality (in-hospital and at 30 days). For time series analysis, segmented regression with a generalized additive model (GAM) assessed the effect on in-hospital mortality. Secondary analysis using difference-in-differences and linear regression assessed in-hospital and 30-day mortality. The study was not powered for time series analysis on 30-day mortality.ResultsWe included 10143 patients, median age 35 (IQR 26 – 50), 83% men. Using time series analysis, we observed a significant reduction in in-hospital mortality(32% vs 24%; OR 0.56, 95% CI 0.4-0.77, p<0.001)in the intervention arm, with no significant change in the control arm. Difference-in-differences analysis found a significant reduction in 30-day mortality(39% vs 26%; DiD estimate -0.15 95% CI -0.19 to -0.11, p<0.001)and in-hospital mortality(32% vs 24%; DiD estimate -0.12 95% CI -0.16 to -0.09, p<0.001). However, external factors such as the opening of a dedicated trauma center at one intervention hospital and the COVID-19 pandemic may have influenced these results.ConclusionImplementing a trauma quality improvement program using audit filters may reduce mortality. More research is needed to confirm these findings across different settings and to understand by which mechanisms these programs mediate the effect and ensure sustainability in terms of improving outcomes.Trial registrationTrauma Audit Filter Trial,ClinicalTrials.govIDNCT03235388,https://clinicaltrials.gov/study/NCT03235388Key pointsQuestionDoes implementing a trauma quality improvement program using audit filters improve mortality in adult trauma patients?FindingsIn this prospective, multicentre, controlled interrupted time series including 10143 patients across four tertiary care hospitals in urban India, we observed a significant reduction in all-cause 30-day and in-hospital mortality after implementing a trauma quality improvement program using audit filters.Meaningimplementing trauma quality improvement programs using audit filters may reduce mortality. However, these programs require local adaptation, and their effectiveness is dependent on the setting, context and maturity of the health care system.